1
Fifth stage
Gynecology
Lec-4
د.براء
1/1/2014
HIV infection
Objectives of the lecture
To know HIV infection
to understand its presentation
to know its complication
to uderstand AIDS
to know about T B infection
Acquired immunodeficiency syndrome [AIDS] is caused by infection with human
immunodeficiency virus [[HIV] which is a retro virus with single strand RNA . it integrates
into the host's cell (CD4 T lymphocyte cells), causing a decline in CD cell and end with:
acquired immunodeficiency syndrome
Clinical presentation
*Twenty percent of patients had acute illness few weeks after infection with fever,
lymphadenopathy,rash,pharyngitis,& conjunctivitis.
*Adecline in immune function in the first few years manifested by non life threatening
opportunistic conditions as recurrent candidiasis,herpes&warts with skin problems.
*The median time to the development of AIDS is ten years.
AIDS is defined as the onset of life-threatening opportunistic infections or malignancies
Common manifestations of AIDS
1-pulmonary :pneumocystic carinii pneumonia ,tuberculosis.
2-neurological :cerebral toxoplasmosis,cryptococcal meningitis,AIDS dementia.
3-gastroentestinal:diarrhoea and wasting syndrome ,oesophageal candidiasis.
4-ophthalmic :cytomegalovirus retinitis.
5-malignancy:kaposi sarcoma,non-hodgkins lymphoma.
6-systemic:mycobacterium avium intracellulare complex [MAX] infection
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DIAGNOSIS
HIV infection is diagnosed by finding antibodies to the outer membrane viral protein
gp-120.
there is often lymphopenia or thrombocytopenia on blood count,
polyclonal Ig G produce a rised total protein count
Monitoring the disease is by measuring the level of CD4 lymphocytes in the
peripheral blood, its normal level is more than 0.5/Lit. There is 10% risk of AIDS
developing within one year when the level decreased to 0.2/Lit.
Transmission
the majority of infections have been
-acquired through
*sexual relationship or
* I-V drug use,
*genital infections are risk factors for HIV ,good control of sexually transmitted
infections should reduce incidence of HIV infection.
-Vertical transmission occurs in 25-40% of pregnancies,
*the majority occur during parturition.
* Breast feeding accounts for 15%transmission.
To reduce risk of vertical transmission:
1-avoiding breastfeeding.
2-elective caesarean section.
3-antiviral medication during the later half pregnancy & to the neonate for six weeks.
Gynecological manifestations of AIDS
1. Genital warts which is due to HPV infection that persist despite aggressive surgical
treatment &may result in development of cervical carcinoma, vulval intra-epithelial
neoplasia & Bowens disease.
2.
Other pelvic infections can be more persistent
3.
Post-partum endometritis is common
4.
Eruptions of secondary genital herpes can become widespread, severe and persist for
weeks as deep painful ulcerations.
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Treatment
Combinations of antiretroviral drugs include nucleoside analogue reverse transcriptase
inhibtors, such as zidovudine . Or a non nucleoside analogue reverse transcriptase
inhibtors such as nevirapine & one of protease inhibtors drugs.
Treatment & prevention of opportunistic infections.
Regular administration of antifungal agents.
Pelvic tuberculosis
Pelvic tuberculosis is becoming uncommon in developed countries & seen more frequently
in developing countries where pulmonary T.B. is common
It is almost always secondary to a focus else where in the body mainly pulmonary
(Mycobacterium tuberculosis), and sometimes intestinal (Mycobacterium bovis).
In younger women may present with amenorrhea, infertility or in similar fashion to PID
with chronic low-grade pelvic pain.
2nd group are older often post-menopausal, who experience reactivation of a former
disease & present with irregular menstrual or post- menopausal bleeding.
Tubes will be involved in all cases
The endometrium in 90% cases
Ovary in 20% ( tubo-ovarian abscess).
Cervix, vagina, or vulva in < 1%
Examination is normal in many women but an adnexial mass or fixing of the pelvic organs
may be detected .
Macroscopical changes
Frequently the tubes are a thickened with fibrosis &peritubal adhesions
the fimbria remain averted not clubbed
tubes are patent but not functioning
caseation within the wall not the lumen
caseation, chronic inflammatory cells and langhans giant cell.
The endometrial changes will be less obvious in premenopause due to regular shedding
but more classical in postmenopausal women
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Diagnosis
Can be performed by
obtaing endometrial tissues in the premenstrual phase which show the
presence of tubercles part of the tissue send for bacterial cultures.
Chest –X-ray is taken .
Treatment
Consists of *antimicrobial chemotherapy & *occasionally surgical remoral of grossly
damaged organs under antimicrobial care.
Rifampicin & isoniazid are taken in a combined preparation of 450-600mg daily plus
prophylactic pyridoxine along with ethambutol 15mg/kg/day for the first two months as
initial phase treatment .
Ethambutd is then discontinued & rifampicin with isoniazid continued daily for a total of 9
months